ICU Planning and Designing

INTENSIVE CARE UNIT

( ICU)

 It is a department with dedicated medical, nursing and allied staff. It operates with defined policies; protocols and procedures should have its own quality control, education, training and research programmes. It is emerging as a separate specialty and can no longer be regarded purely as part of anaesthesia, Medicine, surgery or any other speciality. It has to have its own separate team in terms of doctors, nursing personnel and other staff who are tuned to the requirement of the speciality. ICU development is fast catching up

,there has been stupendous growth in this area but much needs to be done in area of infrastructure, human resource development, protocol, guidelines formation and research which are relevant to Indian circumstances. An acceptable and logistically feasible no compromise can be made on quality and health care delivery to critically sick, yet an acceptable guidelines can be adopted for making ICU designing guidelines which may be good for both rural and urban areas as also for smaller and tertiary centres which may include teaching and non teaching institutes .

 

 

 

 

 

 

 

 

ICU Planning and Designing

 

 

1  Initial Planning

·      Team Formation and Leader/Coordinator

·      Data Collection and analysis

·      Beginning of the Process and decide about Budget allocation , aims and objectives

 

 

2  Decision About ICU Level, Number of beds, Design and Future Thoughts

·      Planning level of ICU like I, Level II or Level III or Tertiary Unit

·      Number of beds and number of ICUs as needed for the institution

·      Designing each bed lay out and providing optimum space for the same

·      Modulation according to various types of space availability

·      Free hanging power columns Vs head end panel facilities

 

 

 

3 Central Nursing Station designing and planning

- Location, space, Facilities 2

 

 

 

 

 4 Equipmentation

 

·      Will depend on number of beds, target level of the ICU

·      Most important decisions will be No of Ventilated beds and Invasive monitoring

·      ICU Vs HDU

·      Collecting information about various equipments available with specifications

 

5 Support System Recommendations

·      Storage

·      Communication

·      Computerisation

·      Meeting needs of Nursing and Doctors

·      Meeting needs of relatives and Attendants

·      Relationship and Coordination with other areas like ER and other super speciality ICUs

 

 

6 Environmental Planning

·      Effective steps and planning to control nosocomial infections

·      Flooring, walls, pillars and ceilings

·      Lighting

·      Surroundings

·      Noise

·      Heating/ AC/Ventilation

·      Waste disposal and pollution control

·      Protocol about allowing visitors, shoes etc inside ICU

 

 

 

 7 Human Resource development

 

Doctors , Nurses , Respiratory Therapist , Computer Programmer , and support staff like Clerks ,X-ray technician, Lab technicians , Cleaning staff who are trained to the needs of ICUs . This is a very Critical area and turn over is very high because of big gap between demand and supply and can put a lot of stress on the team and patient outcome.

 

8 Other areas like

·      Research

·      Data Collection

·      Documentation

·      Record keeping

 

 Team Formation

·      Team may consist of following –

·      Intensivist

·      Administrator

·      Finance officer Architect and Engineers

·      Nurse

·      Any other person if is relevant 3 Who should Co-ordinate/lead the team

 

 

Aims and Objectives, Budget allocation and other target settings

It is important to decide about priorities based on inputs from Team members and should answer following questions –

·      Budget available

·      Level of ICU needed

·      Location

·      Number of Beds needed

·      Designs

·      Human Resource Development

·      Engineering and designing constraints

·      What type of Case mix the ICU team is likely to deal with and therefore help in prioritise equipment type

·      In Case of existing facility being upgraded or relocated, then the review of past mistakes

·      Patient safety and prevention of infection programme

·      Transition in case of relocation during reconstruction of the existing ICU

Following thoughts may help in making decisions and implementation easier

·      Features that must be adopted

·      Features that should be adopted

·      Features that can be adopted

·      Features that should not be adopted

·      Features that must not be adopted.

 

 

 

 

 When every thing has been put in writing and approved by the whole team, the process must be began in the earnest and a time frame work should be fixed and all efforts must be made to accomplish the implementation within the stipulated time unless there are unforeseen circumstances.

 

 

 

Budget and Human Resource (Residents and Nurses) are the most important limiting factors. Engineering related problems like drainage systems, leaks, slopes etc are easily overlooked. It is advised that engineering work be done in a manner so that repairing when ever needed should be easily possible without jeopardising patient care. Therefore, least concealed or over-the-false roof pipelines, wires should be avoided.

 

 

 

 

 

 

 

 

 

 

 Designing ICU/Level/No of ICUs/No of Beds and Individual Bed

 Following ICU Levels are proposed

 

 Level I

·      It is recommended for small district hospital, small private Nursing homes, Rural centres

·      Ideally 6 to 8 Beds

·      Provides resuscitation and short-term Cardio respiratory support including Defibrillation.

·      ABG Desirable.

·      It should be

·      able to Ventilate a patient for at least 24 to 48 hrs and Non

·      invasive Monitoring like - SPO2, H R and rhythm (ECG), NIBP, Temperature etc Able to have arrangements for safe transport of the patients to secondary or tertiary centres

·      The staff should be encouraged to do short training courses like FCCS or BASIC ICU Course.

·      In charge should be preferably a trained doctor in ICU technology and knowledge

·      Blood Bank support

·      Should have basic clinical Lab (CBC, BS, Electrolyte, LFT and RFT) and Imaging back up (X-ray and USG), ECG

·      Some Microbiology may be desirable

·      At least one book on Critical Care Medicine as ready reckoner

 Level II (Recommendations of Level I Plus)

·      Recommended for larger General Hospitals

·      Bed strength 6 to 12

·      Director be a trained/qualified Intensivist

·      Multisystem life support

·      Invasive and Non invasive Ventilation

·      Invasive Monitoring

·      Long term ventilation ability

·      TC Pacing

·      Access to ABG, Electrolytes and other routine diagnostic support 24 hrs

·      Strong Microbiology support with facility for Fungal Identification desirable

·      Nurses and duty doctors trained in Critical Care

·      CT must & MRI is desirable

·      Protocols and policies for ICUs are observed

·      Research will be highly recommended

·      Should be supported ideally by Cardiology and other super specialities of Medicine and Surgery

·      HDU facility will be desirable

·      Should fulfil all requirements for IDCC Course

·      Resident doctors must be exposed to FCCS course/BASIC course/Ventilation workshops and other updates

·      Blood banking either own or outsourced

Level III (All recommendations of Level II Plus)

·      Recommended for tertiary level hospitals

·      Bed strength 10 to 16 with one or multiple ICUS as per requirement of the institution

·      Headed by Intensivist

·      Preferably Closed ICU 5

·      Protocols and policies are observed

·      Have all recent methods of monitoring, invasive and non invasive including continuous cardiac output, SCvO2 monitoring etc

·      Long term acute care of highest standards

·      Intra and inter-hospital transport facilities available

·      Multisystem care and referral available round 24 hrs

·      Should become lead centres for IDCC and Fellowship courses

·      Bedside x-ray, USG, 2D-Echo available

·      Own or outsourced CT Scan and MRI facilities should be there

·      Bedside Broncoscopy

·      Bedside dialysis and other forms of RRT available

·      Adequately supported by Blood banks and Blood component therapy Optimum patient/Nurse ratio is maintained with 1/1 pt/Nurse ratio in ventilated patients.

·      Protocols observed about prevention of infection

·      Provision for research and participation in National and International research programmes

·      Patient area should not be less than 100 sq ft per patient (>125 sq ft will be ideal). In addition there is optimum additional space for storage, nursing station and relatives

·      The unit is assisted by an Ethical Committee which formulates policies about DNAR, Organ donation, EOLS etc

·      Doctors, Nurses and other support staff be continuously updated in newer technologies and knowledge in critical Care

 

·      There is regular sharing of knowledge, mishaps, incidents, symposia and seminars etc relateclosely to the department and in association with other specialtie

 

 

How many ICUS and Beds are needed 

·      Brain storming sessions should be held as to decide how many ICU beds are needed and how many ICUs should be made which may include Advanced ICU, HDU, PICU and Speciality related ICU like Neurointensive care, Cardiac Intensive Care and Trauma.

·      The number of Intensive Care beds will depend on the data available from the hospital and current/future requirements of the hospital.

·      Some ICUs particularly in Private set ups in our country may be main speciality in the hospital and they should be very careful in deciding about the number of beds and budgetary provisions and viability issues are very important in such cases.

·      Numbers of ICU Beds recommended in a hospital are usually 1 to 4 per 100 hospital beds

·      ICUs having 24 are difficult to manage and major problems may be encountered in management and outcome.

·      Recommendations suggest that efficiency may be compromised once total number of beds crosses 12 in ICU.

·      The Canadian Department of National Health and Welfare has developed a formula for calculating the number of ICU beds required based on the average census in the existing unit and the desired probability of having an ICU bed immediately available for a new admission.

·      Therefore, it is recommended that total bed strength in ICU should be between 8 to 12 and not 14 in any case 8

 

 

 

 Location/entry/exit points of ICU in Hospital

·      Safe, easy, fast transport of a critically sick patient should be priority in planning its location, therefore, ICU should be located in close proximity of ER, Operating rooms, trauma ward.

·      Corridors, lifts & ramps should be spacious enough to provide easy movement of bed/ trolley of a critically sick patient.

·      Close/easy proximity is also desirable to diagnostic facilities, blood bank, pharmacy etc

·      No thoroughfare can be provided through ICU.

·      There should be single entry/exit point to ICU, which should be manned.

·      However, it is required to have emergency exit points in case of emergencies and disasters.

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